Hospital Responsibility &
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Date: June 16, 2003 DSL-BQA
To: Hospitals HOSP 06
From: Jane Walters, Chief, Health
via: Susan Schroeder, Director, Bureau of Quality
The Bureau of Quality Assurance (BQA) enforces the state administrative
code governing hospitals, Chapter
DHS 124 (exit DHS), and is the State Agency with whom the Centers for Medicare
and Medicaid Services (CMS) contracts for enforcement of Medicare
regulations governing hospitals. CMS directs BQA to conduct random
validation full surveys in accredited hospitals; CMS also directs BQA to
conduct surveys focusing on specific complaints in accredited hospitals
that, if substantiated, could be a violation of a federal Condition of
Participation for Medicare.
BQA has noted an increase in the number of persons who contact BQA,
after having contacted a hospital about dissatisfaction with physician
services, and report that a hospital representative told them that the
physician was an "independent contractor." Some complainants
then inferred, and others have reported being told, that the hospital did
not have control of or responsibility for the physicianís actions. Some
have reported having been referred to the physicianís practice or
employing clinic to file a complaint. These complainants also frequently
report that they received no written response from the hospital regarding
their complaint or grievance.
Hospitals are reminded that in both state and federal regulations, the
hospital has responsibility for the quality of medical care provided in
their hospital. Medical staff members must apply for privileges to
practice in hospitals and be approved for these privileges by the
governing body of the hospital. This contractual relationship includes the
hospitalís responsibility for quality assessment and performance
improvement, as specifically referenced in the new Medicare Condition of
Participation found at 42
CFR 482.21 (exit DHFS):
- The hospital must develop, implement, and maintain an effective,
ongoing, hospital-wide, data-driven quality assessment and performance
- The hospitalís governing body must ensure that the program
reflects the complexity of the hospitalís organization and services;
involves all hospital department and services (including those
services furnished under contract or arrangement); and focuses on
indicators related to improved health outcomes and the prevention and
reduction of medical errors.
- The hospital must maintain and demonstrate evidence of its QAPI
program for review by CMS.
Chapter HFS 124.12(2) requires that:
- The hospital shall have a medical staff organized under by-laws
approved by the governing body. The medical staff shall be responsible
to the governing body of the hospital for the quality of all medical
care provided patients in the hospital and for the ethical and
professional practices of its members.
The provision at HFS 124.12(4)(c) 4 allowing "temporary staff
privileges may be granted for a limited period if the individual is
otherwise properly qualified for membership on the medical staff"
does not suspend the hospitalís responsibilities for the ethical and
professional practice of medicine in the facility.
Federally, regulations at 42 CFR 482.12(a)(5) require that the
governing body must "ensure that the medical staff is accountable to
the governing body for the quality of care provided to patients."
Federal regulations specifically address services provided under contract,
which includes physician services provided under contract, at 42 CFR
- The governing body must be responsible for services furnished in the
hospital whether or not they are furnished under contracts. The
governing body must ensure that a contractor of services (including
one for shared services and joint ventures) furnishes services that
permit the hospital to comply with all applicable conditions of
participation and standards for the contracted services.
Hospitals are also reminded that federal regulations at 42 CFR 482.13
(a) 2 regarding patient rights require the hospital to respond to patient
complaints and grievances in writing:
- In its resolution of the grievance, the hospital must provide the
patient with written notice of its decision that contains the name of
the hospital contact person, the steps taken on behalf of the patient
to investigate the grievance, the results of the grievance process,
and the date of completion.
Please share the information contained in this memo with your medical
staff and all hospital staff who receive complaints or grievances from
hospital patients. Also, please review your hospitalís policies and
procedures relating to patient complaints about physician care. Thank you
for your prompt attention to this important matter.
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